Using Immersive Technology to Educate Home Dialysis Patients
Two years ago Samuel landed in the hospital unexpectedly after his kidneys failed. It was scary for Samuel and his family. Fortunately, he was in good hands with his care team and nephrologist and soon started dialysis treatments at a treatment facility in a nearby town. Samuel has been on hemodialysis ever since, driving 10 miles to the dialysis clinic three times each week. He spends hours there and feels tied down, with little opportunity to travel or relax at home with family and friends. But time isn't his only obstacle to maintaining some sense of normalcy — he just doesn't feel up to doing anything following his treatments.
Recently, a friend at work told Samuel how home dialysis had been the right decision for his wife, so Samuel wanted to learn more and decided to follow up with his doctor. He talked to his nephrologist who then directed him to a number of websites where he could find documents describing the pros and cons of home dialysis. Samuel struggled to fully comprehend how his day-to-day life would be different on home dialysis, but in the end, he decided that he wanted to give it a go. [For a discussion of the problems associated with medical device decisions based solely on documents follow this link.]
Although different dialysis providers offer different training curriculum, Samuel’s dialysis provider offered a 12 week home dialysis training course that promised to train Samuel on the home dialysis machine. The education and training curriculum involved a combination of online learning (at home) for approximately 4 weeks and once a week in-person classroom instruction at the dialysis clinic’s training facility for 8 weeks.
The learning curve was steep, especially since Samuel had no healthcare experience upon which to build. He found the online learning to be challenging and he struggled to grasp the terminology and to paint a picture in his head of what it would be like to actually care, maintain, and use the dialysis machine. Even so, and after a lot of fits and starts, Samuel was able to learn the information contained in the online classes and reading materials, and he was able to pass the written exam required to move to the in-person classroom phase. Unfortunately, it took him 8 weeks, not 4 weeks to gain enough knowledge to pass the test.
Although a bit discouraged by the extra time needed to pass the written test, Samuel was excited to start the in-person training. Upon entering the in-person classroom though, something unexpected happened.
When Samuel showed up for his first week of in-person training, very little seemed familiar. The information he had covered and memorized in the online classes did not translate well to the hands-on practical tasks in front of him. The picture in his head of what home dialysis would be like was completely different from what he was learning in the in-person classroom. In fact, at times he was not even sure whether the instructor was covering the same material.
These struggles to reconcile the online training with the in-person hands-on training continued for the duration of Samuel’s training, and these struggles led Samuel to require 12 weeks, not 8 weeks to complete the in person, hands-on training.
Though Samuel's training program was originally supposed to last 12 weeks, he and many of the other dialysis patients in his class needed 20 weeks to feel adequately prepared to care, maintain, and operate the home dialysis machine unsupervised.
A broader challenge
Consider the situation facing any dialysis patient like Samuel who recently decided to switch from in-clinic to in-home dialysis. The patient must be educated and trained on all aspects of the specific dialysis machine being used. This includes a cognitive understanding of the machine such as each part, its function, and the steps needed to follow to care, maintain, and use the machine. This also includes a behavioral understanding of the machine such as how to connect all of the relevant parts, in what order, as well as how to hook a patient up to the machine and run it. Behavioral learning can only occur through experience.
Samuel is not alone when it comes to facing difficult decisions about his care throughout his journey as a patient with kidney disease. For more than 37 million Americans with kidney disease today, the challenges of learning about kidney disease are rivaled only by those dealing with learning about available treatment options. On the one hand, patients remain eager to learn, so they turn to written materials and online research to find out more about their diagnosis. On the other hand, as patients face new choices involving their treatment, one-on-one conversations with their nephrologists become an invaluable and primary resource.
Figure 1. We collected responses from nephrologists practicing across the US to learn more about how they currently educate their patients about kidney disease and their treatment options.
Figure 2. We collected responses from patients with kidney disease across the US to learn more about how they choose to learn about kidney disease and their available treatment options.
Although the details are beyond the scope of this report and can be found here, suffice it to say that cognitive learning occurs in the prefrontal cortex of the brain, and requires working memory and attention, both of which are limited capacity resources (see Figure 3). Behavioral learning occurs in the striatum, a subcortical structure in the brain and requires real-time immediate feedback to increase the prevalence of correct behaviors, and decrease the prevalence of incorrect behaviors. Experiential learning involves the sights, sounds, tactile and olfactory aspects of a learning environment by engaging the occipital, parietal, and temporal lobes of the brain.
Figure 3: Learning and performance systems in the brain.
Figure 4 shows the timeline for the typical approach to dialysis device training. Time-to-train is on the x-axis and behavioral competence with the dialysis machine is on the y-axis. The figure depicts the type of training as well as the learning and performance regions in the brain activated by that training. Samuel began with online text-based education. Notice that text-based education engages only the cognitive system in the brain, and thus no behavioral competence is obtained. This learning takes place in an experiential vacuum. This is challenging and time-consuming, and taxes working memory and attention to the limit. Samuel’s online education culminated in a competence test that he had to pass to move on to hands-on clinical training with an instructor. In his case cognitive training took 8 weeks.
Figure 4: Timeline of traditional dialysis device training.
It is important that the online education content, and the hands-on clinical training content are aligned. All too often the topics covered do not match, as in Samuel’s case, which slows learning. Usually the clinical training is conducted in a group setting with the clinical educator demonstrating the use of the dialysis machine and the patients mimicking these procedures. This engages cognitive and experiential centers in the brain. Because the emphasis is on a group setting, each patient gets only periodic one-on-one behavioral training. This is denoted by the partially filled pink circle in the figure. Hands-on clinical training is also time-consuming and culminates in a behavioral competence test, at which point the patient is deemed ready to go home and to care, maintain, and operate the dialysis machine unsupervised. In Samuel’s case, hands-on clinical training required 12 weeks. Ongoing “in-home” training, if any, is generally sporadic at best, leading to gradual increases in behavioral competence.
Turning information into experience
Figure 5 shows the timeline for an immersive technology approach to dialysis device training. Training begins with a series of 360 virtual reality (VR) experiences aimed at providing all of the same information presented in the online text-based education, but from an experiential standpoint. Critically, immersive education of this sort engages cognitive and experiential learning centers in the brain in synchrony. This spreads the wealth of information and spreads the burden reducing cognitive load. This speeds learning and retention allowing the patient to demonstrate cognitive competence more quickly and with more confidence. Critically, and unlike typical online text-based education, VR experiences can be constructed that present the patient with challenging situations that they may rarely see at home, but if they do encounter them they could be fatal. This builds a broad knowledge base and situational awareness that does not develop with traditional approaches. Although no behavioral competence is developed, the patient is primed for behavioral learning. In this example initial training occurs within 4 weeks.
Figure 5: Timeline of immersive technology dialysis device training.
Once cognitive competence is demonstrated, the patient enters the interactive VR or augmented reality (AR) training phase. Here a virtual instructor guides the patient through the care, maintenance, and use of the dialysis device. Because the training is one-to-one, cognitive, behavioral and experiential systems in the brain are engaged in synchrony throughout all of the training. This speeds the development of the relevant behavioral repertoire, and quickly culminates in behavioral competence. Samuel is now cognitively and behaviorally competent in 8 weeks, compared to the 20 weeks for traditional training. With VR and AR, ongoing training is also possible. Thus, Samuel can stay current on any changes in the operation of his machine, or a new machine should his be replaced.
On demand, experiential learning
Of course, hybrid approaches are also worth exploring. One is to replace the online text-based education, or to complement it, with 360 VR education. This engages cognitive and experiential learning centers in the brain in synchrony, and builds the broad-based situational awareness that Samuel needs, and that is not addressed with the online text-based education. This could be followed by traditional hands-on clinical training to be complemented with interactive VR/AR assets in the next phase of development.
Although the focus here is on the patient, Samuel, frontline kidney care staff can benefit from the same type of training (follow this link to meet Susan!). In fact, if patients and frontline kidney care staff both obtain the same training, they will have a shared experience that will facilitate effective communication and mitigate any misunderstandings during the modality education process.
Dialysis device education and training that relies on immersive technologies, such as VR and AR, as opposed to traditional approaches that rely on online text-based and hands-on clinical training, lead to faster learning and stronger retention of relevant information. Broad-based behavioral repertoires and situational awareness develop quickly and naturally in patients. Patients are at home quickly and with confidence – one experience at a time.